Coroner's Finding: RS - de-identified

1y · Female·infarction and volvulus of the small intestine due to adhesion from prior nephrectomy

A 19-month-old girl with history of Wilms tumour presented to Launceston General Hospital with vomiting, pain and lethargy. A Children's Early Warning Tool score of 6 triggered mandatory protocols including senior doctor review within 15 minutes and frequent observations. These protocols were not followed. The child was initially treated in the waiting area without documented observations for over 5 hours. Small bowel obstruction was suspected at 4:45am but imaging was delayed and initially appeared normal. Critical diagnosis of small bowel infarction due to volvulus (from surgical adhesions) was missed, delaying transfer to Royal Hobart Hospital until 1:46pm. By then the child was in shock and multi-organ failure. The coroner found that earlier recognition and transfer may have altered the outcome.